Surgical management of gallbladder sarcomatoid carcinoma

AIM:To study the behavior as well as optimal treatment of gallbladder sarcomatoid carcinoma, we reviewed the results of treatment of gallbladder sarcomatoid carcinoma from Chang Gung Memorial Hospital. METHODS:From 1987 to 2005,six patients were diagnosed with gallbladder sarcomatoid carcinoma and treated at our institution.Tumor staging was based on 2002 revised tumor-node-metastasis(TNM)staging for gall bladder cancer from the American Joint Committee on Cancer.The clinical presentation,laboratory data and preoperative workup were reviewed retrospectively. RESULTS:Five patients were female and one was male.The age ranged from 51 to 66 years(median, 58 years).Surgical procedures included three curative resections,two palliative resections and one biopsy. There were two surgical complications(33.3%)and one case of surgical mortality(16.7%).The followup time ranged from 30 d to 5 mo.The median survival was 2.5 mo.The prognosis was extremely poor,even after curative resection and postoperative chemotherapy. CONCLUSION:The prognosis of gallbladder sarcomatoid carcinoma was not dependent on TNM stage and was always dismal.The clinicopathological features were different from those of gall bladder cancer.

Sunitinib for Taiwan Residents patients with gastrointestinal stromal tumor after imatinib treatment failure or intolerance

AIM:To report preliminary results of the efficacy and safety of sunitinib in the management of Taiwan Residents gastrointestinal stromal tumors (GIST) patients facing imatinib mesylate (IM) intolerance or failure.METHODS:Between 2001 and May 2010,199 Taiwan Residents patients with metastatic GIST were treated at Chang Gung Memorial Hospital.Among them,23 (11.6%) patients receiving sunitinib were investigated.RESULTS:Sixteen male and 7 female patients with a median age of 59 years (range:24-83 years) received sunitinib.Twenty-two GIST patients changed to sunitinib because of IM failure and 1 because of intolerance.The median duration of sunitinib administration was 6.0 mo (range:2-29 mo).The clinical benefit was 65.2% [2 complete response (CR),4 partial response (PR),and 9 stationary disease (SD);15/23].In 12 patients harboring mutations of the kit gene at exon 11,the clinical benefit rate (CR,PR,and SD) was 75.0% and 6 patients with tumors containing kit exon 9 mutations had a clinical benefit of 50.0% (not significant,P=0.344).The progression free survival (PFS) and overall survival (OS) did not differ between patients whose GISTs had wild type,KIT exon 9,or KIT exon 11 mutations.Hand-foot syndrome was the most common cause of grade Ⅲ adverse effect (26.1%),followed by anemia (17.4%),and neutropenia (13.0%).During the median 7.5-mo follow-up after sunitinib use,the median PFS and OS of these 23 GIST patients after sunitinib treatment were 8.4 and 14.1 mo,respectively.CONCLUSION:Sunitinib appears to be an effective treatment for Taiwan Residents with IM-resistant/intolerant GISTs and induced a sustained clinical benefit in more than 50% of Taiwan Residents advanced GIST patients.

Prognosis and feasibility of en-bloc vascular resection in stage Ⅱ pancreatic adenocarcinoma

AIM:To establish the prognosis and feasibility of en-bloc vascular resection of stage pancreatic adenocarcinoma of the head and uncinate process.METHODS:We retrospectively analyzed 87 patients with stage pancreatic adenocarcinoma,who were subjected to pancreaticoduodenectomy (PD) and pylo-rus-preserving PD (PPPD) between 1996 and 2006 in Chang Gung Memorial Hospital,Taiwan. Twelve and 75 patients underwent PD/PPPD with and without resection of portal vein/superior mesenteric vein (PV/SMV),respectively.RESULTS:The overall 1-and 3-year survival rates of patients undergoing PD/PPPD with and without vas-cular resection were 50.0% and 16.7%,and 44.4% and 12.2%,respectively. Morbidity and mortality rates in the PV/SMV resection vs non-resection group were 50.0% and 0.0%,and 40.0% and 2.7%,respectively. In multivariate analysis,serum bilirubin,histological differentiation and adjuvant chemotherapy were independent prognostic factors that influenced survival.CONCLUSION:In stage adenocarcinoma of the pancreatic head and uncinate process,serum bilirubin,histological differentiation and adjuvant chemotherapy were independent prognostic factors,and en-bloc vascular resection is a feasible option in carefully selected patients.

Efficacy of surgical resection in management of isolated extrahepatic metastases of hepatocellular carcinoma

AIM:To clarify the benefit of surgical excision for patients with extrahepatic metastases of hepatocellular carcinoma(HCC). METHODS:We retrospectively reviewed the medical records of 140 patients with pathologically proven extrahepatic metastases of HCC and evaluated the outcomes of those who had undergone surgical resection(SR)for extrahepatic metastatic lesions.Prognoses made on the basis of extrahepatic metastatic sites were also examined. RESULTS:The survival rates of patients who underwent SR of extrahepatic metastases were significantly better than those of patients who did not receive SR. For the SR group,1-and 3-year survival rates were 24%and 7%,respectively,while for the non-resection group,the survival rates were 8%and 0%,respec- tively(P<0.0001).Survival rates related to metastatic sites were also significantly superior after SR of extrahepatic metastases:median survivals were 32 mo with lung metastasis,10 mo with bone metastasis,6.1 mo with brain metastasis. CONCLUSION:SR can provide survival benefits forpatients with 1 or 2 isolated extrahepatic metastases and who concurrently exhibit good hepatic functional reserve and general performance status as well as successful treatment of intrahepatic HCC.

Hepatic resection for hepatocellular carcinoma in end-stage renal disease patients: Two decades of experience at Chang Gung Memorial Hospital

AIM: Hepatocellular carcinoma (HCC) is a common disease in Taiwan. The prevalence of viral hepatitis infection and the subsequent development of HCC are well known to be higher in patients with end-stage renal disease (ESRD) requiring hemodialysis (HD) or peritoneal dialysis (PD) than among the general population. However, information on hepatic resection for ESRD-HCC patients is limited. METHODS: The clinical features of 26 ESRD-HCC patients who underwent hepatic resection from 1982 to 2001 were retrospectively reviewed. Meanwhile, the clinicopathological features and the outcome of 1 198 HCC patients without ESRD undergoing hepatic resection were used for comparison. RESULTS: Of 1 224 surgically resected HCC patients, 26 (4.2%) were ESRD-HCC. Univariate analysis revealed more associated disease, more physical signs of anemia and postoperative complications, lower hemoglobin, platelet, α-fetoprotein, elevated blood urea nitrogen (BUN) and creatinine levels, smaller tumors, lower HBsAg positivity, higher HCV positivity, and longer hospital stays in the ESRDHCC group compared with the HCC group. Furthermore, multivariate stepwise logistic regression analysis revealed that elevated BUN and creatinine levels were the only two independently significant factors in the patients in the ESRD-HCC group. Overall and disease-free survival rates were similar between the ESRD-HCC and HCC groups.CONCLUSION: Elevated BUN and creatinine were the only two main independent factors differentiating ESRD-HCC from HCC patients. ESRD should not be a contraindication of hepatic resection in HCC patients; however, careful operative techniques and perioperative care are crucial to achieving lower morbidity and mortality. Comparable overall survival and disease-free survival can be achieved in selected ESRD-HCC patients undergoing hepatic resection when compared with conventional HCC patients.

Characterization of a novel rat cholangiocarcinoma cell culture model-CGCCA

AIM:To characterize a culture model of rat CCA cells,which were derived from a transplantable TTA-induced CCA and designated as Chang Gung CCA(CGCCA).METHODS:The CGCCA cells were cultured at in vitro passage 12 times on a culture dish in DMEM medium.To measure the doubling time,103 cells were plated in a 96-well plate containing the growth medium.The cells were harvested 4 to 10 d after seeding,and astandard MTT assay was used to measure the growth.The phenotype of CACCA cell and xenograft was determined by immunohistochemical study.We also determine the chromosomal alterations of CGCCA,G-banding and spectral karyotyping studies were performed.The CGCCA cell line was transplanted into the nude mice for examining its tumorigenicity.2-Deoxy-2-(18F)fluoro-Dglucose(FDG) autoradiography was also performed to evaluate the FDG uptake of the tumor xenograft.RESULTS:The doubling time for the CGCCA cell line was 32 h.After transplantation into nude mice,FDG autoradiography showed that the tumors formed at the cell transplantation site had a latency period of 4-6 wk with high FDG uptake excluding necrosis tissue.Moreover,immunohistochemical staining revealed prominent cytoplasmic expression of c-erb-B2,CK19,c-Met,COX-Ⅱ,EGFR,MUC4,and a negative expression of K-ras.All data confirmed the phenotypic features of the CGCCA cell line coincide with the xenograft mice tumors,indicating cells containing the tumorigenicity of CCA originated from CCA.In addition,karyotypic banding analysis showed that the diploid(2n) cell status combines with ring and giant rod marker chromosomes in these clones;either both types simultaneously appeared or only one type of marker chromosome in a pair appeared in a cell.The major materials contained in the marker chromosome were primarily identified from chromosome 4.CONCLUSION:The current CGCCA cell line may be used as a non-K-ras effect CCA model and to obtain information and reveal novel pathways for CCA.Further applications regarding tumor markers or therapeutic targeting of CCA should be addressed accordingly.